Benefits Forms

Please click on each of the following tabs to locate the forms and documents associated with the Benefits topic.

A Complete Guide to Your UC Health Benefits	AD&D Insurance Brochure
Affordable Care Act Exchange Notice	UCnet Forms & Publications
Delta Dental PPO Evidence of Coverage	DeltaCare USA Evidence of Coverage
DepCare Summary Plan Description	Enrollment, Change, Cancellation, Or Opt Out—Employees Only, UPAY850
Health FSA Summary Plan Description	Medical Plan Chooser
Medical Plan Summary	Notice To UC Of A COBRA Qualifying Event, UBEN109
Supplemental Life/Dependent Life Insurance Short-Form Health Questionnaire	Termination of Employment Checklist
Vision Plan Summary of Benefits	For information about temporary layoffs, go to the roadmap - What to do if you're laid off temporarily

A Complete Guide to Your UC Retirement Benefits	Defined Contribution Summary Plan Description
Lump Sum Cashout Factsheet	Qualified Domestic Relations (QDROS) Factsheet
Retirement Handbook	Retirement Initiation Kit Request Form
Returning to UC Employment After Retirement Factsheet	Special Tax Notice for Plan Distributions
Your Guide to Survivor and Beneficiary Benefits	Tax-Deferred 403(b) Summary Plan Description
Tax-Deferred 457(b) Summary Plan Description	UCRP Service Credit Purchase Guide
UCRP 1976 Tier Summary Plan for Members with Social Security

Attending Physician’s Statement	Authorization to Release Medical Records
Authorization to Release Medical Records - Mental Health	DepCare Flexible Spending Account
Disability/Leave Benefits Form (DBF)	Disability Information for Faculty
Family Changes Checklist	Family and Medical Leave Benefits Checklist
FMLA Return to Work Certification	Health FSA
Leave of Absence Request Form	Medical Benefits Summary Booklet
Pregnancy, Newborn and Adopted Child Factsheet	Reimbursement Agreement
Reporting Your Disability Claim English Spanish	UCRP Disability Income
Stay-at-Work/Return-to-Work (SAW/RTW) Program	Supplemental Disability Insurance Plan Booklet
UCR Parking Services - Payroll Deduction/Cancellation Request Form

Sample letters to employees who appointments have changed and will no longer have benefits:

Moving From Core Benefits to No Benefits	Moving from Full Benefits or Mid-Level Benefits to No Benefits
Moving from Full Benefits to No Benefits

Letters to employees whose appointments have changed and their benefits will be affected.

Moving from No Benefits or CORE Benefits to Full Benefits	Moving from No Benefits or CORE Benefits to Mid-Level Benefits
Moving from No Benefits or CORE Benefits to Mid-Level Benefits	Moving from Postdoctoral Benefits to Mid-Level Benefits
Moving from No Benefits or CORE Benefits to Full Benefits for Lecturers (Unit 18)

Human Resources